This application seeks the competitive renewal of an R25 grant-funded project whose long-term goals are to develop, implement, evaluate and institutionalize comprehensive training programs in palliative and end-of-life care at the University of Maryland School of Medicine. During the last funding period, we focused on internal medicine residents, where our goal was to develop, evaluate, and institutionalize required training in palliative and end-of-life care for these learners. Since our residents come from many different medical schools and do not have homogeneous grounding in palliative care, a major thrust during the last funding period was to provide them with a uniform knowledge base in palliative care. This was accomplished by the design, implementation, and evaluation of a comprehensive, Web-based palliative care training program for our medicine residents. Program evaluation revealed that the Web-based palliative care training is feasible, and the residents found it to be of value in their clinical practice. Hence, we have achieved the fundamental goals of the last funding period. However, a knowledge base alone does not assure competence in clinical practice. Competency- based training through direct clinical experience with outcomes-based performance assessed by proficient clinical faculty is needed to assure that our graduate medical learners are competent in palliative care. Hence, for the next funding period, our strategy is to construct a clinical experiential palliative care learning program for medicine residents and medical oncology fellows that will build on the knowledge base provided by the Web-based learning program. This will be accomplished by requiring the residents and fellows to demonstrate competence in essential palliative care domains to their attending physician during clinical rotations. Evaluation of learner proficiency will be done within the framework of the six core competencies for residency education specified by the Accreditation Council for Graduate Medical Education (ACGME) "Outcomes Project." By requiring the residents and fellows to obtain an evaluation of their competency in multiple palliative care domains, our clinical faculty will in turn be requested to make these specific competency evaluations. This provides us with a novel incentive for faculty to learn palliative care content. Hence, we believe that the time is ripe to focus on what may be the "final frontier" in graduating medical residents with competence in palliative care, namely, end-of-life care education for key clinical faculty members. To accomplish this, we formulated the following specific aims: Aim 1: To create specific tools for use by clinical faculty members to evaluate delivery of quality end-of-life and palliative care by medical residents or oncology fellows under their supervision during clinical rotations, using the six competency areas set forth by the ACGME. Aim 2: To educate our internal medicine and medical oncology faculty in content related to palliative and end-of-life care to enable them to use the evaluation tools created in Aim 1 to assess the competency of medical residents and oncology fellows under their supervision in the delivery of quality palliative and end-of-life care during clinical rotations. Aim 3: To apply outcome-based measures to evaluate the effectiveness of the competency-based educational program to determine whether our internal medicine residents and medical oncology fellows follow good palliative and end-of-life care practices.